Vol. 11, No. 12
December 2009
PQ Systems
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Quality Quiz from Professor Cleary

As he was making his patient rounds each day at St. Marble and Glass Hospital, Dr. D. Fib Rillayter kept running into evidence of patients in restraints—those who might be considered risks for hurting themselves or others if they were not restrained. Dr. D. Fib Rillayter knew that while many restraints were applied appropriately for only short periods of time, the mounting use of such restraints for prolonged periods of time was nonetheless troubling.

Asking staff members about the use of restraints generated a number of vague responses: “There was no one available to assist me when I had to leave the patient, so I restrained her;” or “The family wanted him restrained;” “She needed to sleep, so I restrained her.”

Dr. D. Fib Rillayter decided to consult the hospital’s quality manager, Ann S.Thesia, to determine an approach that might track, and ultimately reduce, the number of patients who were restrained.

Ann S. Thesia nodded her head, acknowledging the pattern. “Why are patients restrained, anyway?” she asked. Dr. D. Fib responded with the same vague reasons that he had been given by other staff members.

“Maybe we need to find all the reasons for restraining patients, and then decide what to do to improve the situation,” she said. “It may be that this number of prolonged restraint is necessary; or it may be that it can be reduced—but we need to know why patients are being restrained.”

The next step involved brainstorming with appropriate hospital staff members to try to determine all the reasons that a patient might be restrained for a prolonged period of time. They generated the following list of possible reasons for restraint:

  • Patients are in a strange environment and don’t know what to expect
  • Family is unavailable to discuss alternatives for patient
  • Physicians get irritated when paged or beeped by nursing staff
  • Constant interruptions, especially if there are no Nurse Assistants on the unit
  • Much time is expended in tracking down supplies, paperwork, signatures, etc.
  • Security discourages release of restraint for patients who have been violent – even after they are cooperative
  • Don’t know industry-wide liability interventions
  • Restraints process not clear to everyone (physicians, nurses, patients, families)
  • Don’t understand the difference between language and cognitive abilities
  • Current policy holds individual staff/member at risk if patient becomes disruptive
  • Patient are not aware they have a choice
  • Family not aware they have a choice
  • Patient’s autonomy is not being recognized – we make the rules and assume they know why
  • 24 hour activity in ICU confuses the patient
  • Not enough adaptive equipment
  • Staff fears liability at personal level
  • In-house training insufficient and out of date
  • Doctors renew orders automatically
  • No alternatives are offered to the patient for releasing anger and frustration
  • Current policy out of date regarding regulatory requirements
  • We don’t tell the patients/families the rules or procedures
  • Perception is that patients need to stay in bed at night
  • We focus solely on the physical aspects of the problem – no holistic approach
  • Staff gets too busy to stay with patient
  • Not enough beepers for us to reach physicians
  • Don’t know what the past liability has been for us, prevention efforts and successes
  • In-house training not incorporated into the patient and family orientation procedures
  • No team involvement
  • Hard to reach physicians when nursing concerned about restraint times
  • Current policy not realistic for nursing unit conditions
  • Families of patients need a break – restraints are one way to get it
  • We don’t track how long restraints are kept on patient very well
  • Nurses feel they “own” responsibility for restraint
  • Nursing staff reluctant to “disturb physicians” about restraints
  • Staffing ratio makes it easy to leave patients in restraints
  • Available equipment must be guarded
  • Don’t know alternatives to restraints being used elsewhere in industry
  • Don’t know how other hospitals conduct restraints training
  • Current policy unclear, conflicting direction
  • Current policy definitions of “restraints” conflicting

Now that the team has come up with such a comprehensive list, what will they do with it? “We’ve brainstormed causes for things before, and nothing ever happened after we invested our time in that activity,” one staff member complained. What will be the next step?

a) nothing; seeing all the causes listed will create a sense of responsibility on the part of staff members, and the use of restraints will be reduced through their awareness;

b) creating an affinity diagram to group the causes for further evaluation; this, too, will be enough to improve the situation by breaking old thought patterns;

c) using an affinity diagram to organize the data, and then pursuing further analysis with a relations diagram, cause-and-effect diagram, flow chart, or other tool to identify the area that influences the use of restraints most.


Click here for a more complete video explanation

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